Phantom Limb Pain

Phantom Limb Pain

by Lisa Pavese, FNP, Tory McJunkin, MD, and Paul Lynch, MD.

Phantom limb pain is the sensation that a person has when a body part or limb has been amputated, but still feels as if it is attached. Many amputees have phantom sensations, which are not painful. It is estimated that 85% of people experience phantom limb sensations in the first several weeks following amputation, however, a smaller population of people will continue to feel these sensation for prolonged periods of time. It is reported that 60% of people will continue to experience sensations one year after the surgery (Manchikanti and Singh 2004). Some patients have severe painful debilitating phantom limb sensations. Some of the sensations a patient may feel include tingling, numbness, hot or cold, cramping, stabbing, and burning. The most common sensation that patients continue to feel is pain in the missing limb. These painful sensations can often diminish over time, but some people suffer from long-term pain, which can be difficult to treat.

History

Ambrose Paré, a surgeon in the French military, first recognized the phantom limb phenomenon in 1551, when some of his soldiers reported pain in their missing limbs for long periods of time. A surgeon in the Civil War, Silas Weir Mitchell, first coined the term “phantom limb” in 1871. It was once believed that phantom limb pain originated from painful neuromas that were caused by the original amputation surgery. There are several risk factors for the development of phantom limb pain, including phantom sensations, pain in the stump, pain in the limb prior to amputation, use of a prosthetic limb, and the number of years since the original amputation surgery. The most significant risk factors include amputation of bilateral limbs, and lower extremity amputation. Body parts most associated with the cortex of the brain have a higher risk of developing phantom sensations, such as the fingers and toes. Phantom pain usually occurs in the distal parts of the missing limb. The phantom limb pain may mimic the pain that was present in the limb prior to the amputation (2004). Up until the early 1990s, phantom limb pain was treated by performing additional amputation, shortening the stump, and neuroma removal with hopes that the pain following the initial surgery would be reduced. In 1991, a scientist with National Institute of Health, Tim Pons, discovered that the brain has the ability to reorganize itself if there is sensory deprivation from a part of the body.

Treatment

Some treatments for phantom limb pain include:

  • Medications
  • Physical Therapy
  • Mirror Therapy
  • Interventional Injections
  • Spinal Cord Stimulation.

Medications

Studies have shown that tricyclic antidepressants, sodium channel blockers, and anticonvulsant medications can be useful in neuropathic pain conditions like phantom limb pain. Currently, gabapentin is the most commonly used medication for phantom limb pain. Many studies have shown that oral opioid medications are not effective at treating neuropathic pain. However, a study by Omote, et al (1995) showed that intrathecal administration of buprenorphine was very effective in many patients, and provided them with prolonged resolution of their phantom limb symptoms. Physical Therapy: Desensitization therapies along with sympathetic nerve blocks may provide relief for patients who have “sympathetically mediated pain.” Proper fit of any prosthetic is also important in decreasing pain for many who suffer from phantom limb pain. Mirror Therapy: One of the more promising treatments for phantom limb pain is mirror therapy. Mirror therapy involves the used of a mirrored box with two openings: One for the amputated limb, and one for the other limb. The patient then performs isometric exercises with the non-amputated limb, so it appears as though the amputated limb is moving as well. In a randomized controlled study by Chan, et al. (2007), it was found that the patients who had mirror therapy for four weeks experienced a significant reduction in pain. Interventional

Injections

Injection therapy such as interscalene blocks or stellate ganglion blocks for upper extremity phantom limb pain, or lumbar sympathetic blocks for lower extremity phantom limb pain can also be beneficial. Neuroma injections can also be beneficial for those who suffer with extremity neuromas. These blocks are often combined with physical therapy. Neuromodultion by way of transcutaneous electrical nerve stimulation (TENS) or spinal cord stimulation offers significant relief to many patients who have not had success with other treatment options. Spinal Cord Stimulation (SCS) is often described as a “pacemaker for pain” and uses groundbreaking technology that works by introducing an electrical current into the epidural space near the source of chronic pain impulses. Under a local anesthetic and minimal sedation your doctor will first place the trial SCS leads into the epidural space. The SCS lead is a soft, thin wire with electrical leads on its tip and is placed through a needle in the back into the epidural space. The trial stimulator is typically worn for 5-7 days as the lead is taped to your back and connected to a stimulating device. If the trial successfully relieves your pain you can decide to undergo a permanent SCS if desired. Phantom limb pain can cause severe debilitating pain. Many patients don’t have to suffer. Utilizing multiple treatment modalities carries the most promise of successful management of this undertreated condition. At Arizona Pain Specialists, we offer advanced treatments for phantom limb pain, and provide comprehensive, multidisciplinary care. If you suffer from phantom limb pain, call us today to schedule an appointment!

References

1. Chan B., Witt, R., Charrow, A., et al. (2007). Mirror Therapy for Phantom Limb Pain. New England Journal of Medicine, 2007. 357;21: 2206-2207 2. Manchikanti L. and Singh V. (2004) Managing Phantom Pain. Pain Physician, 2004; 7:365-375. 3. Mayo Clinic (2009). Phantom Pain. Retrieved November 19, 2009 from: http://www.mayoclinic.com/print/phantom-pain/DS00444/DSECTION=all&METHOD=print 4. National Institute of Neurologic Disorders and Stroke (2009). Pain: Hope Through Research. Retrieved on November 19, 2009 from: http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#140643084 5. Omote, K., Ohmori, H., Kawamata, M., et al. (1995). Intrathecal Buprenorphine in the Treatment of Phantom Limb Pain. Anesth Analg 1995; 80: 1030-1032